November 14, 2003 -- In its November 13 episode, "ER" continues its tentative efforts to treat nursing with respect when it's no trouble and doesn't threaten the show's physician-centric worldview, but persistently indulges in damaging inaccuracies and stereotypes when that seems more convenient.

"Death and Taxes," written by co-executive producer Dee Johnson, once again contrasts new nurse Sam Taggart with her major nurse character predecessor Abby Lockhart. Taggart is tough, confident, and unwilling to take anything from anyone. Taggart and intern Gallant engage in a respectful, high pressure discussion about whether to move a critically ill juvenile cancer patient from a poorly equipped clinic back to the hospital. Gallant prevails, but the patient later dies and it is unclear what the right call was. This is fine. When the team finally ceases efforts to revive the patient, Taggart states the time of death, a small thing but a striking dramatic element that the show has almost always awarded to physician characters.

When Taggart becomes the focus of ED medical chief Romano's sexually assaulting prosthetic arm (his unconvincing excuse is that he can't control it), she slams him against the wall, unscrews the artificial hand and takes it away. ED attending Lewis hides it for the rest of the day. This seems like a feminist victory, but treating Romano like an errant schoolboy--you'll get it back when you learn to be nice!--suggests that non-penetrating sexual assault is a matter of boys being boys. In fact, nurses are subject to an unacceptably high number of physical assaults at work, and many would have reported Romano to his superior for disciplinary action, including the possibility of criminal charges, and counseling. In any event, the show clearly means for us to admire Taggart and Lewis.

This hand incident also precipitates what is perhaps the most obvious inaccuracy in the episode, one with which the show seems truly obsessed: that physicians can fire nurses. Romano, upset at losing his hand, tells Taggart she should stop by the "nursing director's office" later where there will be a "pink slip" waiting for her. Taggart responds that that will give her time to prepare her sexual harassment suit. Romano apparently drops the matter. Romano's comment suggests that the show has managed to grasp that there is such a thing as nursing managers who are involved in decisions about nursing employment (though this is not typically the "nursing director," who in most hospitals manages all nursing units throughout the hospital and does not get involved with specific nursing employment issues). But the clear implication is that "ER"'s unseen "nursing director" is a bureaucrat who handles the mechanics of nursing personnel decisions which are made by physicians like Romano. In fact, such decisions are made by experienced nursing professionals who are far more capable than any physician at making decisions about the work of other nurses.

Several elements of the show sent the familiar message that nurses are peripheral subordinates. The show's portrayal of the Filipina nurses who apparently replaced those fired or suspended in the October 9 "Dear Abby" episode remains troubling, for nurses and Filipinas. Just about the only thing the Filipina nurse shown in this episode seems able to utter is an obsequious "Yes, Doctor!" In addition, as in prior episodes, Taggart's troubled young son spends much of her shift either in the ED or missing from the ED, distracting her and other staff. This suggests that single mom Taggart thinks she can treat the ED as day care. At one point, ED attending Kovac--clearly being set up as a surrogate father and possible romantic interest for Taggart--suggests that the boy wait in chairs where "the nurses can take care of him." Later, nurse Chuny is seen looking for the boy. The message: part of the ED nurses' job is to provide day care for other staff, which can be done during their shifts, because it's not like they have any other important duties.

As usual, medical characters were shown doing important tasks that nurses would almost certainly do in real life, including defibrillation, giving medications, and providing support to patients and their families. Perhaps the most striking example is the handling of a male rape victim by Romano. Romano tries to avoid the task and brings his usual level of sensitivity to it, which unintentionally shows why the standard practice in most Level One trauma centers is now that rape care is handled primarily by Sexual Assault Nurse Examiners (SANE) (aka Sexual Assault Forensic Examiners (SAFE)). These are registered nurses with advanced training in forensics and counseling whose assumption of these duties in recent years has vastly improved the care given to rape victims and rape prosecutions. Of course, to show a SANE nurse at work would mean presenting a nurse acting with a very high level of expertise and autonomy in a key area where physicians often play only a minor role. That is a part of modern health care in which "ER" evidently has no interest.

The show's depiction of nurse and now medical student Abby Lockhart deserves a few words. This episode has Lockhart struggling with the academic aspects of medical student life. Fellow student Neela Ragotra does say that Lockhart is excelling at "everything else"--presumably referring mainly to Lockhart's skilled extraction of the information that a patient with a mysterious illness is a crystal meth. user. But Lockhart also seems lost and intimidated in settings with the other students, and continues to absorb outrageous abuse from Romano without any response. The character has always had trouble asserting herself. But she had seemed to gain confidence in the last couple seasons, including with the physicians, and it is odd that such an experienced nurse would suddenly become so meek in the presence of these same physicians and students with little experience. As for the academics, we recall Lockhart saying, long ago, that her earlier medical school grades placed her second in her class. We don't expect every nurse to succeed in every way, but we hope that these discontinuities do not mean the show is falling back on the tired stereotype that nurses are good with people but not very smart or assertive.

TAKE ACTION!

It is imperative that we speak to the makers of "ER" and encourage them to begin portraying nursing accurately.

Bullet points for this episode include:

Physicians cannot hire, fire or supervise nurses. Medicine and nursing are two separate, independent professions and "ER" should stop treating nursing as a subset of medicine;

Modern level one trauma centers have Sexual Assault Nurse Examiners who provide all care for rape victims--including performing the physical exam. Physicians are not involved in such exams except in the case of severe physical trauma. "ER" should depict nurses performing the work of nurses--not physicians;

Nurses do not have time to baby-sit children while they are working. In today's short-staffed hospitals, nurses often do not even have enough time to provide the care their patients need;

Physicians almost never defibrillate or give medications, and it is nurses who provide the vast majority of patient education and support to patients and their families. "ER" should show nurses doing the work of nurses;

Violence against nurses should be accorded proper treatment and those who assault nurses, sexually or violently, should be charged under the legal enforcement system instead of being treated like naughty school children;

"ER" should stop portraying Filipina nurses as barely functional automatons. All nurses must know English and pass nursing boards in order to practice in the US and should be portrayed as competent, fluent nurses.

"ER" has a huge impact on what people around the world think about health care in general, and nursing in particular. "ER" reaches about twenty million households each week in the United States alone. In a recent Kaiser Family Foundation study, more than half of viewers said they learn about health issues on "ER" and discuss them with their friends and family. A third use "ER" to help them make choices about their or a family member's health care.

In 2000, JWT Communications did focus group studies of 1800 youngsters in 10 US cities in grades 2-10. These studies found that the youngsters got their most striking visualization of nursing from "ER," and that they knew more about the nurse character's love life than they did her professional work.

In other words, people learn more about nursing on "ER" than from anywhere else, and they think the inaccurate portrayal of nursing is accurate--which is why it is so essential we convince "ER" to portray nursing more accurately.